Visit for more related articles at International Journal of Emergency Mental Health and Human Resilience
Our global history has been exposed to widespread violence, armed conflicts, terrorism and natural disasters which are unpredictable and devastating due to their nature. According to The UN Refugee Agency, today one in every 122 people has been forced to flee their home due to these reasons, and more than half are children (UNHCR, 2015). According to a WHO and UNHCR report (2015) “adults and children affected by emergencies experience a substantial and diverse range of mental, substance use and neurological problems” (page i).
Our global history has been exposed to widespread violence, armed conflicts, terrorism and natural disasters which are unpredictable and devastating due to their nature. According to The UN Refugee Agency, today one in every 122 people has been forced to flee their home due to these reasons, and more than half are children (UNHCR, 2015). According to a WHO and UNHCR report (2015) “adults and children affected by emergencies experience a substantial and diverse range of mental, substance use and neurological problems” (page i). Besides a local and cultural context, lessons learnt from these disasters include that such human rights violations and traumatic stressors to innocent people produces fear, helplessness, unpredictability, vulnerability and a perception of having nowhere to hide. As a consequence of the recent migrant boats which have resulted in a tragic loss of life in the Mediterranean, asylum is now a major topic of discussion in the media. The UNHCR calls for European-wide protection as a response to the tragedies in the Mediterranean. The benefit of this case allows for the possibility to speak out, not only on the physical and emotional impact that this tragedy has on survivors and the reception countries at large, but also about post-migration growth and resilience. To evaluate the sustainability of the gained knowledge over time, “there is a great critical need to move beyond descriptive cross-sectional research to incorporate longitudinal designs and studies of interventions to improve mental health outcomes” (Pollard et al., 2014, page 383). My framework is based upon two decades of research and clinical care on the physical and mental health effects of war and other widespread violence.
The international literature on adult reactions to potentially traumatic events has focused on the pathogenic perspective. Plenty of data have shown that individuals with a refugee background are at greater risk of pathogenic (negative) trauma outcomes, such as physical and psychological illnesses, than the general population, e.g. a 10-fold risk for post-traumatic stress syndrome (PTSD) (Fazel et al., 2005). New data shows that also childhood adverse experiences needs to be into account in research and treatment planning for adult refugees with war and human rights violation (Opaas & Varvin, 2015). PTSD is often overlooked in primary care but which is the first line of psychiatry (Taubman-Ben-Ari et al., 2001). Studies also show comorbidity with PTSD, such as public health diseases including depression, diabetes and cardiovascular disease (Rasmusson et al., 2010), anger (Roth, Ekblad & Prochazka, 2009), a higher risk of external causes of death compared to non-refugees (Hollander et al., 2012) and higher rates of unemployment and disability (Hollander et al., 2013). Furthermore, there is a dose-effect relationship between cumulative trauma and the diagnosis of PTSD and depression (Mollica et al., 2014). As more people migrate for different reasons, settling or taking refuge in reception countries with a native language other than their own, there is an increased need for access to work as well as to mental health care with culturally competent and multilingual clinical staff.
Bonanno (2004) has highlighted the distinction between resilient persons and those individuals who show a more gradual recovery from traumatic life events. This alternative approach has presented a need to understand the concept of resilience, which can offer protection against the development of psychopathology in times of stress (Hoge et al., 2007). Resilience seems to be a learned human trait from observing how others in our environment respond to traumatic events. Resilience, which is perceived as a multidimensional reality, involves both internal and external factors. Further, more recent concepts, stress-related growth (Park et al., 1996) and posttraumatic growth, involve the perception of positive changes that happens as a result of struggling with highly challenging life crisis, such as traumatic life events (Tedeschi & Calhoun, 2004). It is proposed “that posttraumatic growth mutually interacts with life wisdom and the development of the life narrative, and that it is an ongoing process, not a static outcome” (Tedeschi & Calhoun, 2004, page 1).
Finally, we need longitudinal data at an individual and community level. For instance, positive coping mechanisms may give information about a person’s resiliency. We can potentiate resilience through creating safe spaces (either physical spaces or through the bonds between people) that facilitate recovery. Resilience may also be rediscovered within therapeutic settings between a patient and clinical staff, where empathy and active listening may strengthen an individual’s ability to recognize their capacities while realizing what has helped them so far during difficult times of disaster management. Ahern et al., (2006) have published a review of instruments which measure resilience. Hobfoll et al., (2007) have identified five empirically supported intervention principles that can be used to guide and inform intervention and prevention efforts at the early to mid-term stages. Post trauma symptoms reduce when the person perceives: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, in which there are two critical components for efficacy: (3.1) requires behavioral repertoires & skills; (3.2) empowerment without resources is counterproductive and demoralizing, 4) connectedness, including specific strategies to address discord among family members and 5) hope for normalization as soon as possible. A model of community resilience rests upon a network of adaptive capacities to prevent the personal and social healing that all civil societies are capable of handling, e.g., economic development, social capital, information and communication, community competence (Norris et al., 2008).
In conclusion, there is a need for using a scientific and cultural methodological approach to increase the resilience within postmigration growth while reducing suffering and minimizing disability for survivors of traumatic life events worldwide, therefore this should be a priority in the reception of asylum seekers. We need to change our attitudes and give priority to understanding the wellbeing of a refugee and evaluate the environmental factors that may influence this.
Ahern, N.R., Kiehl, E.M., Sole, M.L., & Byers, J. (2006). A review of instruments measuring resilience. Issues in Comprehensive Pediatric Nursing, 29(2), 103-125.
Bonanno, G.A. (2004). Loss, trauma and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20-28.
Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet, 365(9467), 1309-1314.
Hobfoll, S.E., Watson, P., Bell, C.C., Bryant, R.A., Brymer, M.J., Friedman, M,J., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70(4):283-315.
Hoge, E.A., Austin, E.D., & Pollack, M.H. (2007). Resilience: Research evidence and conceptual considerations for posttraumatic stress disorder. Depression and Anxiety, 24(2), 139-152.
Hollander, A-C., Bruce, D., Ekberg, J., Burström, B, & Ekblad S. (2013). The association between reason for immigration and poor mental health – a population-based register study. The Journal of Nervous and Mental Disease, 201(8), 645-652.
Hollander, A-C., Bruce, D., Ekberg, J., Burström, B., Borrell, C., & Ekblad, S. (2012). Longitudinal study of mortality among refugees in Sweden. International Journal of Epidemiology, 41(4), 1153-1161.
Mollica, R.F, Chernoff, M.C., Berthold, S.M., Lavelle, J., Lyoo, I.K., & Renshaw, P. (2014). The mental health sequelae of traumatic head injury in South Vietnamese ex-political detainees who survived torture. Comprehensive Psychiatry, 55(7), 1626-1638.
Norris F.H., Stevens, S.P., Pfefferbaum B., Wyche, K.F., & Pfefferbaum, R.L. (2008). Community resilience as a methaphor, theory, set of capacities and strategy for disaster readiness. American Journal of Community Psychology, 41(1-2), 127-150.
Opaas, M., & Varvin, S. (2015). Relationships of childhood adverse experiences with mental health and quality of life at treatment start for adult refugees traumatized by pre-flight experiences of war and human rights violations. The Journal of Nervous and Mental Disease (in press).
Park, C.L., Cohen, L., & Munch, R. (1996). Assessment and prediction of stress-related growth. Journal of Personality, 64(1), 71-105.
Pollard, R.Q., Betts, W.R., Carroll, J.K, Waxmonsky, J.A., Barnett, S., deGruy II, I.F.V., et al., (2014). Integrating primary care and behavioral health with four special populations. Children with special needs, people with serious mental illness, refugees and deaf people. American Psychologist, 69(4), 377-387.
Rasmusson, A.M., Schnurr, P.P., Zukowska, Z., Scioli, E., & Forman, D.E. (2010). Adaptation to extreme stress: post-traumatic stress disorder, neuropeptide Y and metabolic syndrome. Experimental Biology and Medicine, 235(10), 1150-1162.
Roth, G., Ekblad, S., & Prochazka, H. (2009). A longitudinal study of self-rated aggression in a sample of adult massevacuated Kosovars. Torture. Journal on Rehabilitation of Torture Victims and Prevention of Torture, 19(3), 227-237.
Taubman-Ben-Ari, O., Rabinowitz, J., Feldman, D., & Vaturi, R. (2001). Post-traumatic stress disorder in primary-care settings: prevalence and physicians' detection. Psychological Medicine, 31(3), 555-560.
Tedeschi, R.G., & Calhoun, L.G. (2004). Posttraumatic Growth: Conceptual Foundations and Empirical Evidence. Psychological Inquiry, 15(1), 1-18.
UNHCR calls for a European-wide protection response to the tragedies in the Mediterranean. http://www.unhcr.org/5537ac7e9.html
UNHCR UK. A world at war: number of refugees at highest level recorded. [email protected] June 18, 2015.
World Health Organization and United Nations High Commissioner for Refugees. (2015). mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO.